Pandemic Plan



PANDEMIC PLANPerioperative Department2020guideline index:COVID-19 Perioperative Department Guidelines……………………………………………………………………….2-7PPE summary……………………………………………………………………………………………………………………………..8Safety Huddle Checklist………………………………………………………………………………………………………………9Main Operating Theatre Maps……………………………………………………………………………………………..…..10-133E Map…………………………………………………………………………………………………………………………………….. 133W Maps………………………………………………………………………………………………………………………………….. 14-16Supporting document for theatre maps………………………………………………………………….………………… 17-19Respiratory Plus Transfer to Theatre from ICU/Ward……………………………………………………………….. 20Respiratory Plus Transfer to ICU/Ward from Theatre…..………………………………………………………….21COVID-19 Anaesthetic Intubation/Extubation Checklist…………………………………………………………..22Tracheostomy management ………………………………………………………….............................................23-24Specimen Collection……………………………………………………………………………………………………………………25Code Blue Management……………………………………………………………………………………………………………..26-27Blood Management……………………………………………………………………………………………………………..…….28-29Theatre Cleaning Checklist.............................................................................................................. 30PANDemic plan:Please note that the versions and dates of updates are noted at the bottom of each document. This is an ever evolving pandemic and thus we will endeavour to update guidelines in accordance with DHHS, hospital guidelines and IPSS in a timely manner.Staff this document applies to:Surgical StaffAnaesthetic StaffNursing StaffTheatre TechniciansAncillary staff key points:COVID-19 (SARS-CoV-2) is a novel, infectious Coronaviridae that can cause critical illness.Transmission is primarily spread via contact and droplets however when undertaking aerosol-generating procedures (AGPs), airborne precautions are recommended.The risk of aerosol transmission is reduced once the patient is intubated with a closed-circuit ventilator.Due to the possible variants within a procedure in the Perioperative Department, all procedures involving a suspected or confirmed COVID-19 case will be treated under Respiratory Precautions Plus for the duration of the procedure, not solely for intubation or extubation (AGPs).purpose:To ensure the safety of all perioperative staff who are involved in the care of a suspected or confirmed COVID-19 patient.To ensure optimal care of patients in the Perioperative Department with suspected or confirmed COVID-19.To guide perioperative staff on the operational flow and management of the operating theatres in the event of a reoccurring outbreak where multiple suspected or confirmed COVID-19 patients are requiring perioperative services.Roles and respsponsibilities: Anaesthetic Consultant in chargeIdentify patients with suspected or confirmed COVID-19 infection in consultation with the Surgical Team, Floor Coordinator, PACU in charge and technician in charge at time of booking. In the event of a COVID-19 case occurring after hours, the consultant anaesthetist on-call MUST be informed.Floor CoordinatorNotify all necessary members of the operating theatre team and coordinate safe transport of patient to and from operating theatres.Liaise with A Bay staff and Ward/ICU staff to alert them to timing of the surgical procedure and impending arrival. Patient will proceed directly to the operating theatre without holding in A Bay.PPE ChampionBe up to date with current advice and practices and attend donning and doffing training weekly.Observe and support the operating theatre team in correct donning and doffing procedures to ensure staff safety.Initiate a team safety huddle prior to patient arriving. Ensure all operating theatre PPE trolleys are stocked at all times.Assist in organising perioperative staff to attend PPE training sessions and simulations.Document questions, concerns or flows that did not work in practice and follow up with management team for review and clarification.In the event of a Respiratory Plus Code Blue ensure staff do not enter the operating theatre without appropriate PPE and divert excess staff away from the operating theatre.Anaesthetic Team Consists of 2 anaesthetists and 1 anaesthetic nurse.Check the anaesthetic machine, equipment for airway management and drugs required.Remove all excess equipment and trolleys from the operating theatre. Equipment that cannot be removed must be covered, where applicable.Liaise with all members of the operating theatre team to ensure readiness to receive the patient.The anaesthetic nurse is to take a phone handover from the ward nurse prior to patient arrival, completing a procedure safety checklist (IP23C).Ensure patient proceeds directly to the operating theatre and enters/exits through the main doors.Facilitates the transfer of the patient from the bed/trolley to and from the table.Recover the patient in the operating theatre unless they are an ICU transfer.Liaise with the floor coordinator to initiate transfer of the patient to ward/ICUAssist in the cleaning of operating room surfaces and clinical equipment and disposal of infectious waste.Surgical TeamConsists of 2 surgeons, an instrument nurse and a circulating nurse.The surgeon will notify anaesthetic consultant in charge (#6311) and floor coordinator (#6312) when booking a case for a patient who has suspected or confirmed COVID-19.Ensure a clear surgical plan is communicated with the operating theatre team and all required equipment and instruments are available.Ensure when available?consultant is performing procedure to reduce surgical time.Remove all excess equipment from the operating theatre. Equipment that cannot be removed must be covered, where applicable.Assist in the transfer of the patient from the bed/trolley to and from the table.Assist in the correct positioning of the patient for the procedure.Discuss the need for specimen collection with appropriate operating theatre team members and complete required pathology forms.Assist in the cleaning of operating room surfaces and clinical equipment and disposal of infectious waste.Ensure all surgical and anaesthetic equipment is collected into a case cart.In the event the patient is recovered in the operating theatre, either the instrument or circulating nurse must remain in the operating theatre as support for the anaesthetic nurse.Theatre TechnicianResponsible for setting up operating theatre equipment required for the specific procedure.Remove all excess equipment from the operating theatre. Equipment that cannot be removed must be covered, where applicable.Ensure patient proceeds directly to the operating theatre and enters/exits through the main doors.Assist in the transfer of the patient from the bed/trolley to and from the table.Remove all linen from patients’ bed and place in a linen skip.Remove patient bed/trolley from the operating theatre. Outside technician will wipe the bed/trolley down with Clinell (Universal) green wipes and make the bed with fresh linen.Assist the surgical and anaesthetic teams where required.Assist anaesthetic team in the transfer of a patient to and from Ward/ICU.Assist in the cleaning and disinfecting of operating room surfaces and clinical equipment and disposal of infectious waste.Theatre RunnersConsists of 1 Anaesthetist, 1 Anaesthetic Nurse, 1 Circulating Nurse & 1 Technician. Ensure adequate PPE is available for operating theatre team in ‘clean area’, including an emergency supply. Ensure adequate supply of hand sanitiser and Clinell wipes are available.Place appropriate signage around the operating theatre to clearly mark infection control zones and doors.Document ASCOM phone number on the whiteboard inside the operating theatre and note the operating theatre phone numbers. Ensure operating theatre phone is in working order including speaker setting.Remove all excess equipment from the ante and doffing areas. Equipment that cannot be removed must be covered, where applicable.Directly supervise and assist members of the operating theatre team in the donning and doffing of PPE.Supervise and maintain infection control measures and theatre flow during the procedure.Act as a runner for the operating theatre team, collecting additional equipment or medications and completing any tasks required (such as documentation) outside of the operating theatre while maintaining infection control measures and theatre flow. Transcribe any documentation completed inside operating room theatre staff. The scribe must document their name, signature, date and time transcribed on any documents transcribed. Any documentation within the operating theatre must be discarded. No ‘clean’ documentation is to be in the operating theatre.Hold consent and timeout forms up to the window for the operating theatre staff to observe during the timeout process. A staff member involved in the timeout process will sign the documentation at the completion of the procedure. A laminated copy of the time out form will be available to use a template inside the operating room.These staff members will be stationed in the ‘clean area’ outside the operating theatre.Be on standby to enter the operating theatre for Respiratory Plus code blues (only after correct donning of PPE).Liaise with ward staff for transfer back to ward and guide staff who come and collect the patient on where to correctly don and doff. Liaise directly with the rostered PPE champion in the event of doubt or concern.Assist in the cleaning of operating room surfaces and clinical equipment and disposal of infectious waste.Ensure all surgical and anaesthetic equipment is collected into a case cart and immediately send to CSSD for munication:There is to be minimum 1 portable ASCOM phone per theatre. 2 portable ASCOM phones are required for off the floor procedures.The runner staff should have the phones in the ‘clean area’ for the duration of the procedure and the numbers should be documented on the whiteboard prior to patient arrival.The phones within the operating theatre can be set to loudspeaker to avoid handling near the face.operational flow to manage increase in COvid-19 patients:Patients to bypass admissions bay and go directly into the designated operating room.If it is not possible for patients to go directly to theatre, suspected or COVID-19 patients with a surgical mask in-situ must be managed pre operatively in recovery bay 21.Operating theatre 11 is the first Respiratory Plus operating theatre and must remain vacant and setup for the availability of a patient with suspected or confirmed COVID-19.Where operating theatre 11 is occupied, theatre 12 can be utilised.Where operating theatres 11 & 12 are in use, operating theatres 15 and 16 will be utilised.In operating rooms 15 & 16 one can be a COVID-19 positive whilst the other a non COVID-19 theatre. The set up room/doffing room will be cleared and closed off to non COVID-19 theatre. Staff will need to be aware of not entering/exiting the non COVID-19 theatre as the COVID-19 patient is in transfer as they share a corridor. All emergency cases where a patient history cannot be obtained should be treated as a suspected COVID-19 case.In the event of a trauma patient requiring operating theatre 13 (vascular), operating theatre 5 (cardiac), operating theatre 7 (Neuro) or operating room 4 (orthopaedics) COVID-19 theatre flows must be followed. See below. These operating room theatres can work independent of their neighbouring operating theatres so should not impact those current flows.In the event that either operating theatre 11, 12, 15 & 16 are in use an operating theatre that has the ability to work independent of neighbouring operating theatres should be utilised. These are 1, 4, 5, 6, 7, 13 & 14In the event that theatres 11, 12, 15 & 16 are occupied by suspected or confirmed COVID-19 patients, zoning of the remaining theatres must be set up.Theatres 1-4 will be prepared for the COVID theatre flows and once at capacity, operating theatres 7-9 will be prepared.Theatre 10 cannot be utilised for COVID flow as there is no available ante room.There is a ‘care after death’ COVID-19 clinical practice guideline available on the intranet/workplace to refer to if indicated. This is to be used in conjunction with current practises already in the perioperative department.left288COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES PPE Summary00COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES PPE SummaryStaff safety is the number one priority for Melbourne Health. These guidelines outline the recommended PPE to use during the COVID-19 pandemic. Please note: this is a rapidly changing situation and these PPE guidelines may be updated as the situation evolves: ppe summary for NOn suspected or confirmed covid-19:Day of surgery/admission: Standard precautions and risk assessment.Admissions bay: During COVID-19 pandemic nurse to wear a surgical mask. If patient is coughing ++ give patient a surgical mask as well.Intubation: Anaesthetic team (and technician if requested by anaesthetist to be in room) to wear contact/droplet precautions (surgical mask, protective eye wear, gown and gloves) to be change between each case. During intubation non-essential staff to leave the room.Surgery/Procedure: Perioperative attire as per policy (Perioperative Attire and Hygiene POS POS01.20 & Surgical Scrubbing, Gowning and Gloving POS01.15) (surgical gown, protective eyewear, surgical mask and gloves).Extubation: Anaesthetic team (and technician if requested by anaesthetist to be in room) to wear contact/droplet precaution (surgical mask, protective eye wear, gown and gloves) to be changed between each case. During extubation non-essential staff to leave the room.Recovery: Standard precaution (protective eye wear and surgical mask). For all LMA/guedel and nasopharyngeal contact/droplets precaution applies (surgical mask, protective eye wear, gown and gloves).Stage 2 Discharge: Standard precautions. If patient is coughing ++ give patient a surgical mask as well.Perioperative ppe summary for suspected or confirmed covid-19:ALL procedures involving a suspected or confirmed COVID-19 cases will be treated under Respiratory Precautions Plus for the duration of the procedure due to the many possible variants and quick patient deterioration within our department.0-1905COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Safety Huddle020000COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Safety HuddleSafety Huddle prior to patient arriving in theatre:1.Team introductions. Roles of everyone, who is going to be inside theatre or runner? Please write on gown your name and role.6286587259002.Who is going to be the team leader?59750117223003.How are you going to communicate with outside? Write phone numbers up on the whiteboard or piece of paper to be placed on the wall and thrown out after case. 51123249579004.What is the airway plan? Any extra anaesthetic equipment/monitoring required?42173130175005.What is plan for surgery, e.g. specimens, dressings, sutures and drains? 50537121920006.What equipment is?required for the surgery from tech? E.g. stools, lavage.50165130546007.Radiology team required? Do those staff members understand flow/donning/doffing.50429121285008.Post op plan. Anaesthetic nurse to recover or direct to ICU? Ensuring a scrub/scout nurse will remain in the theatre if patient being recovered until ward transfer. 50800250082009.Flow of theatres, in particular donning and doffing areas.511241399750010.Does patient have group & screen? Discuss need for blood products & plan for giving these. 505372597150011.Antibiotics/VTE prophylaxis.424971252630012.Does everyone feel comfortable and confident with the plan?505371244600013.Questions?508004762500Ensure anaesthetists, anaesthetic nurse, technician, scrub and scout nurse, surgeons and outside runners are present. Only staff actively involved in the case should be present in theatre – no observers. All belongings e.g. phones, lanyards to be left outside before donning. 2619375-276288500-381000-5715000left-2900left458003619500569595018002253286125962025STAFF ENTRY 00STAFF ENTRY 4524375107632540100251085850298132510858503362325673103E – Whole ward will be managed as ‘hot’ if required due to physical layout. 003E – Whole ward will be managed as ‘hot’ if required due to physical layout. 61055251049020STAFF EXIT00STAFF EXIT5909945129667051054001515745DONNING00DONNING542925021634455155565165798500586676516579850055816501915795DOFFING00DOFFING47244003173095WARD 3EAST00WARD 3EAST76200-13335000 -5742940673103W – When only one room is required for a COVID-19 procedure. 40000200003W – When only one room is required for a COVID-19 procedure. 26574755429253W – When two rooms are required for concurrent COVID-19 procedures. 40000200003W – When two rooms are required for concurrent COVID-19 procedures. 0-13335000-55911752197103W – When two rooms are required for concurrent COVID-19 procedures. 4000003W – When two rooms are required for concurrent COVID-19 procedures. 7448550-38931856667500-39789105991225-398843504848225-39884353743325-39789107286625-37312602962275-51028603W – When all rooms are required for concurrent COVID-19 procedures. 4000003W – When all rooms are required for concurrent COVID-19 procedures. 70008752457450STAFF ENTRY/EXIT00STAFF ENTRY/EXIT56578501933575STAFF EXIT00STAFF EXIT1333507429500-11607801619250-19418301552575-1313180170497500-3702685155257500-2618105155257500-23895051619250-4932045155257500left162COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Supporting Document for Flow Maps.00COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Supporting Document for Flow Maps.CLEAN AREA (Blue zone)ANTE ROOM (Amber Zone)CONTAMINATED AREA (Red Zone)OPERATING ROOMDOFFING AREAThe scout nurse will don respiratory plus precautionsThe scrub nurse will don booties, hat, N95 mask and goggles.Surgeons who wish to assist in patient positioning must don respiratory plus precautions.Additional anaesthetic staff that did not assist in transfer of the patient will don respiratory plus PPE in ‘CLEAN AREA’ and enter via the ‘ANTE ROOM’ ONLY.The scrub nurse will proceed to the ‘ANTE ROOM’ to perform the surgical scrub and don the surgical gown and gloves.The scrub and scout nurses will enter the OR through the ‘ANTE ROOM’.Surgeons will then proceed to the ‘ANTE ROOM’ to perform the surgical scrub and don the surgical gown and gloves. Where an item needs to be passed into the OR it must be through the ‘ANTE ROOM’ only. The runner will open the outer door to the ‘ANTE ROOM’, place item on trolley and close the outer door. The trolley will be situated close to the door so the runner does not need to enter ‘ANTE ROOM’. The inside staff member can then open the inner door of the ‘ANTE ROOM’, take the required item and return to the OR with the inner door closing behind them.The red ‘CONTAMINATED DOORS’ between the ‘CLEAN AREA’ and OR must NOT be accessed under ANY circumstance. Paper documentation can occur inside the room but needs to be transcribed onto a clean document by outside runner and the ‘dirty’ document must be thrown out during cleaning phase. Prior to patient arriving to theatre and intubation the scrub and scout nurses will set up required instrumentation inside the OR.Before patient enters room any tray tins should be removed from OR. Any tray tins or items that are still in the OR once patient has arrived must not be removed from the OR until the completion of the procedure.On arrival, the patient will enter the pink ‘CONTAMINATED DOORS’ only and not through the ‘CLEAN AREA’ (see map).The pink ‘CONTAMINATED DOORS’ should not be used as an access point at any time except patient transfer to and from the OR.The patient will be recovered in the OR with anaesthetic nurse and scrub or scout nurse present. Anaesthetist may leave room once patient stable and anaesthetic nurse happy.Surgeons post assisting with positioning the patient and is ready to scrub will leave the OR through ‘DOFFING’ area to safely doff their gown and gloves leaving their booties, N95 mask, hat and goggles on. After the equipment has been removed the scrub or scout nurse may doff their PPE and exit through the ‘DOFFING’ room.For the removal of surgical instruments, the runner scout nurse will push the opened case cart up to the outer doors of the ‘DOFFING’ area. The scrub or scout nurse will load all contaminated instruments and anaesthetic equipment DIRECTLY into the case cart. You do not need to put the instruments into the tins if tins are already in case cart.The runner will close the case cart, tag the cart with a contaminated priority tag and send directly to CSSD. DO NOT leave the case cart unattended in the tug room.GENERAL GUIDELINESThe flow into and out of the OR should always be one way. IN via the ‘ANTE ROOM’ and OUT via the ‘DOFFING’ area.Patient is to go directly into the theatre not to admissions bay or anaesthetic room.Staff in the ‘CLEAN AREAS’ do not need to be in PPE.After the patient has been transferred to the operating table, the inside technician will strip the patients’ bed/trolley of all linen and place in linen bag. The bed/trolley will be removed from the theatre before intubation (via pink doors) and the outside technician who will be wearing gown and gloves, will clean the bed with Clinell (Universal) green wipes.The patient can be transferred to their bed for extubation.Patient will be transferred to the ward/ICU following the patient transfer guidelines.All staff are responsible for cleaning of the theatre following the CLEANING PROCEDURE.Donning and doffing should always be performed in pairs.Take your time when donning and doffing.Never enter a red zone without PPE, no exceptions.If there are any concerns or questions, these should be directed to the PPE champion only.right370COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Supporting Document for Flow Maps.020000COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Supporting Document for Flow Maps.HEALTHCARE WORKERCLEAN AREA (Blue zone)ANTE ROOM (Amber Zone)CONTAMINATED AREA (Red Zone)OPERATING ROOMDOFFING AREASurgeon (who assisted with positioning the patient)Don respiratory precautions plusPerform the surgical scrub and don the surgical gown and glovesSurgeons post assisting with positioning the patient and is ready to scrub will leave the OR through ‘DOFFING’ area to safely doff their gown and gloves leaving their booties, N95 mask, hat and goggles on.Surgeon (who DID NOT assist with positioning the patient)Don booties, hat, N95 mask and gogglesPerform the surgical scrub and don the surgical gown and glovesDoff PPE and exit through the ‘DOFFING’ roomScout Nurse/Endoscopy NurseDon respiratory precautions plusSet up required instrumentation inside the ORDoff PPE and exit through the ‘DOFFING’ room.The runner scout nurse will push the opened case cart up to the outer doors of the ‘DOFFING’ area. The scrub or scout nurse will load all contaminated instruments and anaesthetic equipment DIRECTLY into the case cart. You do not need to put the instruments into the tins if tins are already in case cart.Scrub Nurse/Endoscopy NurseDon booties, hat, N95 mask and gogglesPerform the surgical scrub and don the surgical gown and glovesSet up required instrumentation inside the ORDoff PPE and exit through the ‘DOFFING’ roomThe scrub or scout nurse will load all contaminated instruments and anaesthetic equipment DIRECTLY into the case cart. You do not need to put the instruments into the tins if tins are already in case cart.Anaesthetic Staff and Technician (didn’t assist with transfer)Don respiratory precautions plusDoff PPE and exit through the ‘DOFFING’ roomleft453COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Supporting Document for Flow Maps.020000COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Supporting Document for Flow Maps.For OR 2, staff should move to the ‘DOFFING’ area behind 1 to doff their PPE.9172215047500For OR 3, staff should move to the ‘DOFFING’ area behind 4 to doff their PPE.1075498-268800104363025261200For OR 8, staff should move to the ‘DOFFING’ area behind 7 to doff their PPE.For OR 9, staff should move to the ‘DOFFING’ area behind 10 to doff their PPE.For OR 13 & 14, the ‘DOFFING’ and ‘ANTE ROOM’ are considered shared space. This is the only room for entering and exiting the ORs.For OR 13 the red ‘CONTAMINATED DOORS’ between the ‘CLEAN CONTROL ROOM’ and OR MUST NOT be accessed under ANY circumstance.-47625-133350COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Patient Transfer To Theatre From ICU/Ward.00COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Patient Transfer To Theatre From ICU/Ward.-861314015494000-4996289181582400-6358102600010477519050COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Patient Transfer To ICU/Ward From Theatre.00COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Patient Transfer To ICU/Ward From Theatre.447675-35179000left431COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Tracheostomy Management 00COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Tracheostomy Management PPE:Follow current RMH COVID-19 Clinical Practice Guideline. calling for patient to come to theatre:Notify ward of upcoming transfer to theatre and confirm with RN the presence of tracheostomy.If the patient does not have a HME filter provide theatre technician with one and (T-bag) to take to ward.Ward RN will attach the HME filter and T-bag to their in-line suction to create a “HME protected open circuit” prior to transfer to A-bay.Patients with a “closed circuit” or a “HME protected open circuit” can be transferred as per usual procedure with standard precautions. IN admissions bay ONLY IF COVID-19 UNDIFFERENTIATED:iF SUSPECTED OR CONFIRMED – BYPASS ABAY STRAIGHT TO OR.Do not perform any AGP - including open suction, humidification or nebulisation. Keep the patient connected to the HME protected open circuit at all times.Intraoperatively:Connect HME protected open circuit to anaesthetic circuit for case. Post-operatively:If patient is undifferentiated can be managed in PACU with a “closed circuit” or “HME protected open circuit”. Patient to be transferred to ward with closed circuit or HME protected open circuit with standard precautions. hme protected open circuit:left273685 HME Filter and t-bag:292417533718500left32766000 left508COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Specimen Collection:020000COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Specimen Collection:Preoperative:The need for taking specimens should be discussed with surgical team prior to the patient arriving during team safety huddle.Specimen forms should be completed by surgeon and placed into specimen bags and pots organised prior to the patient arriving.A sheet of patient labels will be in the theatre and are considered dirty and thrown out after the case. Intraoperative:Specimens will be handed off to the inside scout nurse who will correctly label the specimen and confirm that the pathology form matches the specimen (including 3 points of ID). Place the specimen in the pathology bag and take it into the ante room. The inside scout nurse will drop specimen onto the trolley in ante roomOnce door to theatre is closed the outside runner will then come in with gloves on and place specimen in a second clean bag (or labelled specimen bucket with lid if multiple specimens).Once in clean bag, outside runner can take gloves off and perform hand hygiene.Outside runner to place a highlighted sticker on the bag/ bucket stating this is a suspected/confirmed COVID-19 patient histopathology (stickers kept in COVID-19 folder at floor co-ordinator desk.The number of specimens should be indicated on the outside of the container. The technician runner can then take the specimen to pathology.Post operative:Label specimen book at end of case. Complete iPM as normal.left0COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES CODE BLUE MANAGEMENT020000COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES CODE BLUE MANAGEMENTManagement and considerations COVID-19 code blue:During a Code Blue on a suspected or confirmed COVID-19 patient (this includes all OPSTATS and trauma calls where a patient history has not been obtained e.g. pt. unconscious) the safety of staff is paramount therefore entry to a COVID-19 theatre without PPE is prohibited even if this means delaying initiation of ALS. Protection of staff is based on 2 principles:Strict adherence to Respiratory PPE plus for all staff in the location.Minimising the size of the team responding to the code.The most common causes of “code blue” in the perioperative setting are: Airway ObstructionHypoxiaAnaphylaxisExsanguinationOther considerations include:CPR and bag mask ventilation are aerosol generating procedures (AGP’s). Ideally, CPR would be commenced once the airway is secured with a cuffed endotracheal tube. If high flow oxygen masks and nasal cannulae (AGP’s) are in use turn off the oxygen delivery prior to removing the mask/nasal cannulae to minimise aerosolization.Must attach a HME filter to the airway.Protocol:If an arrest occurs in a suspected or confirmed COVID-19 case, the team should call via the overhead pager “Attention Respiratory Plus Code Blue and location” twice. The code blue button can then be pressed. The Anaesthetic Consultant In-Charge, PACU In-Charge, Floor co-ordinator and technician In-Charge will respond immediately to designate required additional staff members. Additional staff members can include:Anaesthetic consultant responder2 Senior Anaesthetic nurse responders (One of the Nurse responders will be responsible to bringing the COVID-19 Crash Cart [CCC] to the site of the arrest).Scrub/scout nurse responderTechnician responderThe PPE champion/outside runners will ensure staff are not entering the theatre without appropriate PPE and donning under direct supervision. Also diverting excess staff away from the theatre. The size of the team should allow for CPR to be performed with swapping of operators. Contents of COVID-19 Crash Cart (CCC):The CCC is not designed to manage all causes of arrest but assist with the likely arrest pathology we see in theatre. Extra equipment and drugs can be requested from staff located outside theatre.The content of the CCC will comprise drugs and equipment utilized in the early phases of ALS in order to reduce discarding contaminated unused stock.1.Full respiratory plus PPE for 4 people.2.Defibrillator and pads.3.2 bags of fluid and IV giving sets.4.Cannulation equipment.5.Minimum Volume tubing x 16.Arterial line equipment [this can be removed if the patient already has an arterial line]7.Syringes: 2ml, 5ml, 10ml, 20ml, 50mlx1, Blood gas.8.Pathology Tubes: FBE, CUE, Coags, X-Match x 19.Hypodermic needles: 19G, 23G10.Blunt drawing up needles 11.Drugs:a.Adrenaline 1/1000 x 3b.Adrenaline 1/10000 x 2c.Esmolol 100mgd.Calcium Chloride x 1e.Metaraminol x 1f.Normal saline: 100ml bagg.Normal saline ampoules 10ml x 20STAND DOWN OF CODE BLUE:Doffing is to occur according to department policy in the designated doffing area regardless of outcome.There is a ‘care after death’ COVID-19 clinical practice guideline available on the intranet/workplace to refer to if indicated.Team debriefing is essential. The performance of resuscitation is stressful in normal circumstances. Support should be offered and provided for all team members including the opportunity to discuss the events as a team. This will also provide opportunity for quality reviews of the events and inform future practice.0635COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Blood Management – Standard 7020000COVID-19 PERIOPERATIVE DEPARTMENT GUIDELINES Blood Management – Standard 7Blood management in respiratory precautions plus:It is recommended the minimum number of staff required should enter the patient zone.Alternate ways of communication i.e. through phones/speakerphones whilst patient is isolated (accompanied by visual communication through a glass barrier) should be utilised wherever possible.The clinical records should remain outside the patient’s zone (including Blood Product Prescription Form) at all times.Blood product prescribed on Blood Product Prescription Form ( BPPF) IP13Two Clinicians who are permitted to check blood as per MH02.09.06 Blood Component Procedure MH02.09.06 Blood Component Procedure proceed to patient area with Blood Product and BPPFPrior to enter the operating room using the MH Bloodpack checklist both clinicians must simultaneously and independently perform checks of blood against:BPPF INV/H Transfusion Laboratory Form Both clinicians must both agree that all match and correctIf no discrepancies Blood Product is handed to another clinician inside the operating room to continue the patient identification checking process Two new clinicians will complete the Patient Identification checking process with the Blood ProductPatient unable to participate in Positive Patient IdentificationClinician to STATE and MATCH Full name, DOB, MR Number against:ID band Blood Product Two staff doing the patient ID and product check must rely on the accuracy of the ID band. Confirm Blood Product is intended for the patient identified on the ID bandBoth clinicians must both agree that Patient ID match and correct on Blood ProductOne of these clinicians commences transfusion as prescribed and monitors as per guidelineAll four clinicians part of the checking process MUST sign, date and time the BPPF – after removing PPE as per protocolThis guideline should be read in conjunction with MH02.09.06 Blood Component ProcedureHow to check blood products at melbourne health:Remember: You must verify the patient’s identify at each stage of the administration process. Ask the patient (if conscious and able) to state and spell their first and surname name, state their DOB, and ensure they are identical to the identification band.The simultaneous, independent checking procedure involves checking the following details (both staff members must view each identifier independently, in the presence of the other staff member). All details must be correct and identical before the unit is administered to the patient. If any discrepancy in information this MUST be corrected prior to the transfusion taking place.What Where it is locatedTick to confirmPatient identification: First name SurnameDate of birthURN Verbally with patient?Patient ID band?Blood order (Computer screen or paper)?Compatibility label (on product) ?Compatibility report (INV/H)?Product type: e.g. red blood cellsBlood order?Compatibility label (on product)?Compatibility report (INV/H)?Lifeblood label (on bag)?Do not proceed if any discrepancies are found during the checking process – contact the transfusion laboratory. The blood group on the blood pack label must be compatible with the patient’s blood group as indicated on the MH compatibility label attached to the pack. If the blood group of the blood component and the patient are not identical, the transfusion laboratory must make a specific comment to indicate that it is compatible (or the most suitable available).ABO & Rh Blood Group of the patientMH Compatibility label / (INV/H) on product ?ABO & Rh Blood Group of the ProductMH Compatibility label on product?Blood Service Label on product?Donation number or batch numberLifeblood label or product label if batched product?Compatibility label (on product)?Compatibility report (INV/H)?Product expiryLifeblood label or product label if batched product?Compatibility label (on product)?Compatibility report (INV/H)?Crossmatch expiry (RBC only)Compatibility label (on product)?Compatibility report (INV/H)?Integrity of blood product:Blood pack or bottle intact / not leakingColourCoagulation Foreign bodiesDo not proceed if there is any concern regarding the integrity of the product – contact the transfusion laboratory.For further information go to .au/packcheck for further learning resource material. left3600 ................
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